|
 
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| REVIEW ARTICLE |
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| Year : 2014 | Volume
: 1
| Issue : 1 | Page : 14-18 |
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Immediate implant in the esthetic zone: An evidence-based clinical guide
Mansour K Assery
Vice Dean for Post Graduate Studies and Research, Riyadh Colleges of Dentistry and Pharmacy; Chairman of Saudi Board in Prosthodontics, Riyadh, Saudi Arabia
| Date of Web Publication | 2-Jan-2014 |
Correspondence Address:
Mansour K Assery
P. O. Box 84891, Riyadh 11681
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/WKMP-0056.124180
Immediate implant placement in the esthetic zone is a topic that has recently received a lot of attention in the literature. Successful implant placement at the time of extraction in the esthetic zone is a challenge, requiring management of soft-tissue, atraumatic extraction placement of the implant and later the prosthetic stage.
This article looks reviews recent literature on the topic of immediate implant placement in the esthetic zone and the clinical steps involved. The article also looks at recent evidence on patient satisfaction and discusses the merits, demerits of such a procedure and precautions to be taken by the practitioner to minimize failure. Keywords: Anterior teeth, esthetic zone, immediate implant, implant prosthesis
How to cite this article:
Assery MK. Immediate implant in the esthetic zone: An evidence-based clinical guide. Saudi J Oral Sci 2014;1:14-8 |
| Introduction | |  |
Over the past decade, there has been a growing volume of literature on the placement of implants in the Esthetic Zone. [1] The growing consensus among prosthodontists and surgeons is that a successful implant requires not only osseointegration, but also consideration of the gingival esthetics and the esthetics of the final restoration. [2],[3],[4],[5] One of the greatest challenges facing an Implant Practitioner today is dependably and esthetically replacing a maxillary anterior tooth. [6],[7] Traditional techniques have called for tooth removal, alveolar healing, implant placement and integration, uncovering and possible soft-tissue grafting before finally completing the restoration. [8] This can result in multiple surgeries, many months of waiting and a long time wearing an inconvenient interim removable partial denture.
Attempts to shorten the overall length of treatment have focused on the two approaches:
- Early or immediate loading following implant placement. [9],[10],[11],[12],[13],[14]
- Immediate implant placement in the fresh extraction of the natural tooth. [8],[15],[16],[17],[18]
Recently although there has been growing evidence to suggest that immediate implant placement, followed by early implant loading can result in good results for the patient. [19],[20],[21] However, concerns have been raised about the clinical dilemmas associated with the technique. [22],[23] Given this the aim of this review of literature is to describe the technique for a single visit implant placement in the esthetic zone and review the literature to provide the practitioner with evidence based guidelines to minimize complications.
| Criteria for Immediate Implant Placement | | |
One of the factors, highlighted by several authors, to improve the outcome of immediate implants placed in the esthetic zone has been case selection. [1],[17],[18],[23],[24] Immediate implant placement is most commonly indicated when tooth extraction is due to trauma, endodontic failure, root fracture, internal or external resorption, or extensive decay and the bony walls of the alveolus are still intact. [19]
It is contraindicated:
- In the presence of active infection;
- When there is insufficient bone beyond the tooth socket apex for initial implant stability;
- When there is a wide and/or long gingival recession.
Prior to extraction, a tooth should be esthetically evaluated to comprehensively assess the potential implant recipient site. It has been reported that despite atraumatic extraction defects could exist in the alveolar septum that could jeopardize the success of the implant. [17] A proper plan should include a soft-tissue treatment protocol and a set of well-defined esthetic goals. [1],[19]
The tooth to be extracted must be evaluated based on its relative position to the remaining dentition in three planes of space, because the existing tooth position will influence the configuration of the gingival architecture. [17],[25],[26] An optimal extraction situation provides the potential for immediate implant placement if the diameter of the head of the implant closely matches the mesiodistal width of the coronal aspect of the socket. [1],[4]
| Extraction Technique | | |
An atraumatic extraction is the key to successful placement of a single visit implants in the esthetic zone. Recent studies have shown that it is important to ensure that there is both adequate buccal bone thickness [26],[27] as well as an intact inter-alveolar septum [16],[17] to ensure good prognosis of the placed implant.
A number of instruments have been developed for this purpose, including the periotome. The periotome, a slim elevator - like instrument, is introduced into the periodontal ligament space and use to serve the periodontal ligament. This instrument is gradually advanced toward the apex of the tooth. Care should be taken to preserve the thin buccal wall of the maxillary incisors. Sectioning of the tooth and minimally invasive extraction have been proposed as a method to preserve the integrity of the socket whereby the tooth is carefully sectioned and the fragments carefully removed. [16] Recently, a technique of orthodontically extruding the hopeless tooth has been suggested as a means to increase the thickness of the labial bone. [28]
The osseous - gingival tissue relationship must be verified following tooth extraction. The desired level of the free gingival margin must be determined before implant restoration and must be related to the underlying osseous support. [1]
| Implant Placement | | |
Several clinical reports have proposed implant placement without flap elevation (flapless surgery) to minimize bone loss and soft tissue recession. [1],[21] Chu et al. [21] so far as to recommend flap-less extraction and implant placement as a guideline to ensure clinical success of the implant.
Achievement of initial stability of the implant and sufficient quantity and quality of bone present are the key factors for success. [17],[18],[27],[29],[30] Given the fact that atraumatic extraction alone does not guarantee the absence of minor bone defects, especially in the intra-alveolar septum, [17] a host of bone and soft tissue augmentation techniques have been suggested to prevent failure of the implant and ensure good esthetics. [5],[28],[31],[32]
The primary stability of the implant should be the result of mechanical fixation of its implant and can be achieved by engaging the palatal wall and bone more than 2-3 mm beyond the apex of the extraction socket. This can be accomplished by positioning the burs against the palatal wall of the socket during the sequential osteotomy. [1]
Following atraumatic tooth extraction, initial preparation of the osteotomy begins with a 2 mm round drill with copious irrigation, through the surgical guide for optimal mesiodistal positioning. To avoid damage to the buccal cortical plate, the drill tip should be positioned along the palatal wall of the extraction socket, 3-5 mm coronal to the apical end of the extraction socket. [33],[34]
The implant is placed into sound bone along the palatal wall of the extraction site, away from the buccal wall of the socket and the socket itself. Maintaining a small gap between the implant and the labial plate may facilitate secondary bone fill with autogenous bone obtained with the bone collector device and establish thicker, more stable bone thus increasing resistance to bone resorption. [30] The need for bone grafting depends on the thickness of the labial plate rather than the size of the gap since the labial plate has a tendency to resorb in all directions. [18],[29] The final implant diameter should be within the confines of the tooth socket, without engaging the corona portion of the labial plate to prevent perforation and more important, bone resorption and soft-tissue recession. [4],[29]
After an immediate implant placement into extraction socket, it is critical to assess the horizontal space, if any, from the implant surface to the socket wall. It has been shown that no bone augmentation is needed if the peri-implant space is 2 mm or less because spontaneous bone fill and osseointegration will take place when using a rough surface implant. [33] In sites where the peri-implant horizontal defect measures more than 2 mm, a bone regenerating technique is required to predictably achieve bone fill and increase the percentage of bone-to-implant contact.
| Preservation of the Restorative Gingival Interface | | |
Preservation of the gingival papilla and good gingival contour is critical for the esthetic success of implants in the esthetic zone. In this regard, the role of the provisional prosthesis used during the healing period is an important one. [35] The design of the provisional should minimize post-surgical irritation and pressure on the soft-tissue. Immediate installation of a provisional restoration, soft-tissue adaptation to the provisional and no-suture surgery favor soft-tissue healing. [33],[36] The role of the periodontist and the restorative dentist in this regard is an important one and it is critical that a good multi-disciplinary treatment plan is established before the procedure is attempted. [37] The use of scalloped implants and proximal shields for the preservation of the papillary esthetics has been suggested. [38],[39] It has also been shown that long-term stability of papillary esthetics is significantly better in individuals with a thick gingival biotype when compared with those with a thin gingival biotype. [40],[41]
| Occlusal Considerations | | |
During immediate placement of a dental implant in the esthetic zone, utmost care must be given to occlusal considerations. Mild variations may exist depending on whether early or late loading of these implants and the presence of underlying conditions such as periodontitis. [9],[14],[42]
It is generally stated that in the maximum intercuspation and/or exclusive movements of the mandible, contact with the restoration should be avoided. In this way, any forces directed toward the tooth will inevitably be reduced by the interspersed bolus of force. Short of some parafunctional habit involving a hard object, the forces on the underlying healing implant should be relatively few, infrequent and low in magnitude.
| Implant Loading Protocols | | |
Conventionally it has been argued that since, most gingival recession (0.7-0.9 mm) occurs within the first 3-6 months post implant placement and 80% of all sites exhibit buccal recession, a minimum of 3 months should elapse for the gingival tissue to stabilize before either selecting a final abutment or taking the final impression [Figure 1], [Figure 2], [Figure 3]. [1]  | Figure 1: An ideal atraumatic extraction should aim to preserve both interdental papilla and the bone
Click here to view |
 | Figure 2: A conceptual graphic description for implant placement in the anterior esthetic zone
Click here to view |
 | Figure 3: A provisional restoration is placed until healing of the tissue (a) followed by placement of the permanent restoration (b)
Click here to view |
There have been attempts made to load immediate implants with a final restoration soon after implant placement. However, a recent review of the literature showed that the 1 year survival for such implants was only 10%. [9] The same study however also pointed out that there is a paucity of prospective cohort studies addressing patient-centered outcomes and no parameters specific to immediate loading protocols were available for evaluation. [9]
| Advantages of the Technique | | |
The concept of immediate implant placement on the fresh extraction socket has great attention over the last few years. [15] Reports on early and immediate loading have generally been very encouraging [24],[25] , while immediate post-extraction implant placement has allowed prosthetic treatment as early as 3-6 months post-surgery, with excellent esthetic results, along with good bone preservation, reduced treatment time and cost. [24],[25],[26],[27]
Furthermore, this widely used treatment modality has a psychological benefit for patients, as the loss of a tooth can often be a traumatic experience. However, with immediate implants, such "loss" can be limited and timely compensated through simple surgical and restorative procedures that can be completed in just a few months. [3]
| Conclusion | | |
Over the past few years, there have been that studies have shown that immediate implants are comparable, if not superior to delayed placement in terms of survival, bone stability, papillary esthetics and patient satisfaction. [14],[20],[42],[43] In the view of the literature reviewed here it can be predicted that immediate implant placement is a safe and reliable technique to provide implants in the anterior esthetic zone.
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[Figure 1], [Figure 2], [Figure 3]
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